535. ENDOSCOPIC AND THORACOSCOPIC MANAGEMENT OF OESOPHAGEAL PERFORATION

Abstract

Abstract This is a rare case of boerhaave’s syndrome associated with ischaemic small bowel in a young patient. A 45-year-old man, background of schizophrenia, alcohol excess and previous TIAs, presented to resus room in a peri-arrest condition secondary to sepsis. A CT scan confirmed gross mediastinitis with extensive right pleural contamination and an ischaemic segment of small bowel. An intercostal chest drain in resus was placed and drained enteric content from the oesophagus confirming the diagnosis. The patient was immediately taken to operating theatre and a large distal oesophageal perforation was localized on OGD under GA. Using a novel technique, a guide wire was placed into the mediastinal cavity via the perforation. Over the guide wire, an exudrain was placed to act as an endovac (200mmHg wall suction) and a large bore NG tube placed into the stomach. A right sided VATs decortication and wash out and insertion of further chest drains was carried out, followed by laparotomy and resection of a 10cm segment of ischaemic small bowel. Following a short critical care unit stay, the patient made a steady recovery free of any complications. In total, 3 endoscopies were performed post operatively to assess mediastinal healing. Psychotropic medications were delivered through an NJ tube. At 3 weeks, the patient showed complete healing of the oesophageal defect and had a stricture which needed dilatation. Endoscopic negative pressure treatment can be combined with a minimally invasive thoracoscopic approach to the mediastinum to achieve success even in an unstable patient. Vigilance needs to be applied for concomitant pathology such as small bowel ischaemia, although rare, contributes to the risk associated with this serious condition.